Standard 2.1 Healthcare reflects national and international evidence of what is known to achieve best outcomes for service users.
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Features of a service meeting this standard are likely to include: 2.1.1 Healthcare that is delivered according to policies, guidelines, protocols and care pathways that are based on best available evidence. 2.1.2 Use of National Clinical Guidelines and nationally agreed protocols, care bundles and care pathways where available. 2.1.3 Regular reviews of National Clinical Guidelines to determine what is relevant to the care and treatment provided and taking steps to address any identified gaps to ensure guidelines are implemented. 2.1.4 A clearly documented risk assessment when services are unable to fully implement National Clinical Guidelines and appropriate action taken to ensure the quality and safety of services. 2.1.5 Modification of National Clinical Guidelines for use in local practice and consideration of these guidelines when assessing and planning an individual service user’s care. 2.1.6 An evidence-based process for the development of policies, guidelines, protocols and care pathways. 2.1.7 Support for, and facilitation of, the workforce in making decisions based on the best available evidence. 2.1.8 Support for healthcare professionals in making clinical decisions based on evidence which will maximise benefits to service users and minimise unnecessary treatment and care. |
Standard 2.1 requires healthcare to be delivered according to national clinical guidelines based on national and international best practice.
Useful links
The National Clinical Effectiveness Committee (NCEC) is developing a National Suite of Clinical Guidelines. Keep an eye out on their website for further developments.
The HSE National Clinical Programmes.
Link to the Cochrane Library.
You are also required to keep up to date with national and international best practice throughcompulsory CPD.
Contact your Post-Graduate Training Body for enrolment in a Professional Competence Scheme.You should also have access to appropriate peer-reviewed clinical journals.
Link to the Irish Medical Journal www.imj.ie
Clinical Audit
You will need to show that clinical guidelines are used in your practice. Consider carrying out a clinical audit for compliance with clinical guidelines. This will also help you to comply with Medical Council regulations for the Maintenance of Professional Competence.
The Medical Council has produced a number of videos to guide you with carrying out a clinical audit.
Standard 2.2 Care is planned and delivered to meet the individual service user's initial and ongoing assessed healthcare needs, while taking account of the needs of other service users
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Features of a service meeting this standard are likely to include: 2.2.1 Planning and delivery of healthcare in response to an individual service user’s assessed needs that also takes into consideration the collective priorities and needs of service users as a whole. 2.2.2 Assessment of the service user’s individual healthcare needs by the healthcare professional or team with the necessary competencies and information to plan for and deliver healthcare to the service user. 2.2.3 Prioritising the assessment and treatment of each service user according to their needs so that they receive an assessment and treatment that is timely and appropriate to their needs. 2.2.4 Outcome goals that are clearly defined when planning care for individual service users. These goals are: – based on the service user’s assessed needs – agreed between the service user and the identified lead healthcare professional – regularly reviewed and revised to ensure effectiveness – regularly reviewed and revised to ensure they reflect the service user’s changing needs and preferences. 2.2.5 When the healthcare needs of a service user cannot be met within the scope of the service, informing the service user, and, in consultation with them, making the necessary arrangements for transfer of care to the appropriate service. |
See standard 1.1 for planning the delivery of care around patients assessed needs.
Standard 2.2 requires that appropriate evidence-based patient assessment tools are used where available.
See HSE National Early Warning Score
There is also a requirement for health professionals to ensure that the outcome goals are discussed when developing care plans with patients. Ensure these discussions are noted in the patient’s medical record.
Standard 2.3 Service users receive integrated care which is coordinated effectively within and between services.
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Features of a service meeting this standard are likely to include: 2.2.1 Planning and delivery of healthcare in response to an individual service user’s assessed needs that also takes into consideration the collective priorities and needs of service users as a whole. 2.2.2 Assessment of the service user’s individual healthcare needs by the healthcare professional or team with the necessary competencies and information to plan for and deliver healthcare to the service user. 2.2.3 Prioritising the assessment and treatment of each service user according to their needs so that they receive an assessment and treatment that is timely and appropriate to their needs. 2.2.4 Outcome goals that are clearly defined when planning care for individual service users. These goals are: – based on the service user’s assessed needs – agreed between the service user and the identified lead healthcare professional – regularly reviewed and revised to ensure effectiveness – regularly reviewed and revised to ensure they reflect the service user’s changing needs and preferences. 2.2.5 When the healthcare needs of a service user cannot be met within the scope of the service, informing the service user, and, in consultation with them, making the necessary arrangements for transfer of care to the appropriate service. |
See standard 1.1 for planning the delivery of care around patients assessed needs.
Standard 2.2 requires that appropriate evidence-based patient assessment tools are used where available.
See HSE National Early Warning Score
There is also a requirement for health professionals to ensure that the outcome goals are discussed when developing care plans with patients. Ensure these discussions are noted in the patient’s medical record.
Standard 2.4 An identified healthcare professional has overall responsibility and accountability for a service user's care during an episode of care.
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Features of a service meeting this standard are likely to include: 2.4.1 Informing service users who their responsible healthcare professional is, and facilitating discussion about their care between the service user and that healthcare professional. 2.4.2 Clear documentation of the identified healthcare professional with overall responsibility and accountability for a service user’s care at all times. 2.4.3 Timely, formal handover of information and accountability for the overall care of a service user when they move within or between services and the responsible healthcare professional changes; keeping the service user informed of these changes and making explicit the change of healthcare professional and documenting this. 2.4.4 Identification of a healthcare professional who is accountable and responsible for the coordination of a service user’s care, including during an episode of care involving multiple clinical specialties. |
This Standard requires that patients should be explicitly informed about who is/will be responsible for their care. There should be specific arrangements in place for transfer of patients to other healthcare professionals within and between services. Ensure transfer of care to another healthcare professional is appropriately documented in clinical records.
See Standard 2.3 above for Standardised Referral and Discharge Forms
The Medical Council Guide to Professional Conduct and Ethics for Registered Medical Practitioners also states that
“Most people understand and accept that information must be shared within the healthcare team to provide safe and effective care. If disclosure of a patient’s information is necessary as part of their care and treatment, you should take reasonable steps to ensure that you make such a disclosure to an appropriate person who understands that the information must be kept confidential.”
In addition, only information necessary to the care and treatment of the patient should be shared.
See Standard 1.6 on Doctor Patient Confidentiality
The Medical Council Guide to Professional Conduct and Ethics for Registered Medical Practitioners also states that “It is in the best interests of the patient that a general practitioner supervises and guides the overall management of their health.” If a patient has been referred to a consultant by their GP or if a consultant sees a patient without referral. It is advisable that the GP is kept informed of their progress unless the patient objects. Similarly if a consultant refers a patient on to another healthcare professional the GP should be kept informed.
See Medical Council Guide to Professional Conduct and Ethics for Registered Medical Practitioners
Standard 2.5 All information necessary to support the provision of effective care, including information provided by the service user, is available at the point of clinical decision making.
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Features of a service meeting this standard are likely to include: 2.5.1 Relevant information being shared in a timely and appropriate manner to facilitate the transfer or sharing of care within and between multidisciplinary healthcare teams and services from referral through to transfer or discharge. 2.5.2 Necessary information being shared to support the provision of care in a manner that respects service users’ privacy and confidentiality. 2.5.3 Ready availability of accurate, up-to-date and easily retrievable high quality information, including information from the service user, to healthcare providers involved in each individual’s care. |
Patient Records
HIQA is looking to see that service users are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them. As such, healthcare records must be readily available, accurate and up-to-date.
Clinical records should contain:
· History of the condition including positive and negative details
· Allergies
· Examination of the patient including positive and negative findings
· Differential diagnosis
· Details of any investigations requested
· Details of treatment options discussed including risks and desired outcomes of proposed procedures
· Details of patient consent to/refusal of treatment or procedure
· Details of treatment prescribed including drug dosage and duration prescribed, Include batch number and expiry date of medication or vaccinations administered
· Details of referrals made including the name of the healthcare professional referred to
· Follow-up arrangements for investigations, referrals or treatments
· Patient progress including further consultations, improvements or deterioration in the patient’s condition, side effects or complications
Ensure all relevant documents are kept in the patients records including:
- Handwritten notes
- All correspondence to patients including letters, faxes, emails, sms texts
- Referral letters or other correspondence to or from hospital services
- Laboratory results, x-rays, other imaging records
- Photos or other recordings
- Printouts from monitoring equipment
- Consent forms
- Copy of Patient information leaflets or other documents given to the patientOther tips for good record keeping:
- Ensure records are legible - avoid using text speak, abbreviations or shorthand.
- Ensure all records are signed, dated and timed – particularly hand written notes as electronic systems should do this for you.
- Keep to facts and avoid unnecessary comments
- Check letters, faxes, emails and sms messages for potential errors
- Ensure records are legible - avoid using text speak, abbreviations or shorthand.
Security of Patient Records
You are required under the Data Protection Act to keep patient records secure. Ensure that you comply with the requirements under Data Protection legislation
Your Medical Indemnifier can provide you with advice on good record keeping and maintenance
See Medisec Legal Advice on General Practice and Medical Records
See MPS Medical Records in Ireland – An MPS Guide
Standard 2.6 Care is provided through a model of service designed to deliver high quality, safe and reliable healthcare
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Features of a service meeting this standard are likely to include: 2.6.1 Clear description of how the service will be delivered and communication of the scope, objectives and intended quality outcomes of the service through a publicly available statement of purpose. 2.6.2 Delivery of care using high quality, safe and reliable models of service delivery that have the required clinical services, meet legislative requirements and take into account best available evidence, national policies, National Clinical Guidelines if available, local population health needs and available resources. 2.6.3 Necessary arrangements in place for transfer of care to the appropriate service when the service user’s healthcare needs cannot be met within the model of service provided. This transfer process involves clear consultation with the service user throughout. 2.6.4 Regular review of the services provided and evidence that the defined model of service can be delivered safely. This review should include the: i) assessed needs of the population being served ii) size, complexity and specialties of the service being provided iii) interdependencies of internal and external clinical and non-clinical services and support arrangements iv) national and international evidence regarding the model of service or type of service being provided v) relevant legislation and Government policy vi) findings from consultation with key stakeholders vii) number of staff required to deliver the service viii) skill mix and competencies required to deliver the service ix) resources and facilities available x) changes in the workload. The service takes the required action where gaps are identified to ensure quality and safety of services. 2.6.5 Ongoing assessment of the volumes and casemix of their service users to ensure services are provided to sufficient numbers of service users to maintain the skills and competencies of clinical teams based on best available evidence or advice from the relevant professional and expert bodies. This assessment also ensures that clinical teams receive adequate experience of the management of complex and rare conditions and complications. 2.6.6 Management of available resources, including the workforce, to meet legislative requirements, and to deliver the defined model of service safely and sustainably at all times. 2.6.7 Planning, management and delivery of services to maintain the quality and safety of care when demand, service requirements, resources or capabilities change. 2.6.8 Delivery of healthcare within the stated scope of what can be delivered safely and effectively. |
See Standard 5.3 on Statement of Purpose.
This standard requires that services are delivered through an appropriate model to ensure high quality, safe and reliable care. The models of service takes into account: required clinical services; legislative requirements; best available evidence; national policies; National Clinical Guidelines (if available); local population health needs; and available resources.
The standard requires that the model of service delivery is regularly reviewed and that action is taken to identify gaps.
Standard 2.7 Healthcare is provided in a physical environment which supports the delivery of high quality, safe, reliable care and protects the health and welfare of service users.
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Features of a service meeting this standard are likely to include: 2.7.1 Premises and facilities that comply with relevant legislative requirements. 2.7.2 Premises and facilities that are accessible and responsive to service users’ physical and sensory needs where this can be achieved safely, effectively and efficiently. 2.7.3 A physical environment that is planned, designed, developed and maintained to achieve the best possible outcomes for service users for the resources used. 2.7.4 A physical environment that is developed and managed to promote better health and wellbeing for service users and members of the workforce. 2.7.5 A physical environment that is developed and managed to minimise the risk to service users and members of the workforce from acquiring a Healthcare Associated Infection. 2.7.6 Appropriate management of hazardous materials and waste including arrangements for safe handling, storage, use and disposal. 2.7.7 Appropriate measures in place to ensure the security of the premises. 2.7.8 A physical environment that is planned and managed, for example, through ongoing risk assessment and management, to maintain the quality and safety of care when demand, services delivered or resources change. 2.7.9 The proactive identification of risks associated with changes to the physical environment where care is delivered and evaluation of identified risks and necessary action to eliminate or minimise such risks. |
The Health and Safety Authority (HSA) have produced a useful Audit Tool to assist in the continuous development and implementation of a safety and health management system for the healthcare sector. The IMO would recommend that you carry out a Health and Safety Audit in your practice.
This document is to be cross referenced with HAS Guidance Document of the Healthcare Sector.
Keep up to date with regulations on health and safety on the website of the Health and Safety Authority.
Other useful links
Link to HIQA’s National Standards for the Prevention and Control of Healthcare Associated Infections.
Standard 2.8 The effectiveness of healthcare is systematically monitored, evaluated and continuously improved.
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Features of a service meeting this standard are likely to include: 2.8.1 Use of relevant national performance indicators and benchmarks, where they exist, to monitor and evaluate the quality and safety of the care and its outcomes. 2.8.2 Where national metrics do not exist, the development or adoption of performance indicators and benchmarks in accordance with best available evidence to monitor and evaluate the quality and safety of the care provided and outcomes. 2.8.3 Use of a variety of outcome measures to evaluate the effectiveness of healthcare including: – clinical outcomes – service users’ perspectives on their outcomes – service users’ experience of care – feedback from healthcare professionals. 2.8.4 Use of information from monitoring and evaluation to improve care and to disseminate learning. 2.8.5 Monitoring and evaluation of performance by developing and implementing clinical and non-clinical audits and implementing improvements based on the findings. 2.8.6 An agreed annual plan for audit, which incorporates participation in national audit programmes, and local, targeted audits conducted in line with service requirements and priorities. 2.8.7 An evidence-based methodology, in line with national guidelines where they exist, is used in the conduct of audit. 2.8.8 Clinical governance arrangements that ensure findings from clinical audits are reported and monitored effectively. 2.8.9 Dissemination and public reporting of information about the quality and safety of care delivered and quality improvement programmes. 2.8.10 Provision of requested information to relevant agencies, including national statutory bodies, in line with relevant legislation and good practice. |
This Standard recommends that performance indicators and benchmarks be put in place by service providers to measure and assess performance. An annual audit plan should also be put in place.
HSE National Performance indicators.
Annual Audit Plan
Develop an annual audit plan. Ensure issues arising from clinical audits are reported and addressed.
NB: This booklet should be treated as a guidance only.
The IMO rejects any liability and shall not be held accountable for individuals failing to comply with any of the HIQA Standards. Equally, if there is any legislation or standards not mentioned in this guidance that a service provider should be compliant with, you should still comply with that legislation and those standards.